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Liu MZ, Dai XH, Zeng MT, Chen EQ. Clinical treatment of cryptococcal meningitis: an evidence-based review on the emerging clinical data. J Neurol 2024; 271:2960-2979. [PMID: 38289535 DOI: 10.1007/s00415-024-12193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/07/2024] [Accepted: 01/13/2024] [Indexed: 05/30/2024]
Abstract
Cryptococcal meningitis (CM) is a fatal fungal central nervous system (CNS) infection caused by Cryptococcus infecting the meninges and/or brain parenchyma, with fever, headache, neck stiffness, and visual disturbances as the primary clinical manifestations. Immunocompromised individuals with human immunodeficiency virus (HIV) infection or who have undergone organ transplantation, as well as immunocompetent people can both be susceptible to CM. Without treatment, patients with CM may have a mortality rate of up to 100% after hospital admission. Even after receiving therapy, CM patients may still suffer from problems such as difficulty to cure, poor prognosis, and high mortality. Therefore, timely and effective treatment is essential to improve the mortality and prognosis of CM patients. Currently, the clinical outcomes of CM are frequently unsatisfactory due to limited drug choices, severe adverse reactions, drug resistance, etc. Here, we review the research progress of CM treatment strategies and discuss the suitable options for managing CM, hoping to provide a reference for physicians to select the most appropriate treatment regimens for CM patients.
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Affiliation(s)
- Mao-Zhu Liu
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin-Hua Dai
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ming-Tang Zeng
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Wuhou District, Chengdu, 610041, China.
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Naseem MA, Khan MA, Ali W, Danial Malik M, Aslam W. Cryptococcal Meningitis in an HIV-Negative Pulmonary Tuberculosis Patient: A Case Report. Cureus 2023; 15:e45900. [PMID: 37885511 PMCID: PMC10598787 DOI: 10.7759/cureus.45900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Cryptococcal meningitis represents a severe opportunistic fungal infection primarily observed in individuals with compromised immune systems. It frequently manifests in symptoms like headaches, vomiting, cranial nerve complications, and cognitive alterations. However, it's worth noting that up to 15% of cases may exhibit no discernible central nervous system-related symptoms. A 70-year-old male, previously diagnosed with pulmonary tuberculosis and undergoing treatment with anti-tubercular medications, was admitted due to changes in consciousness, sporadic low-grade fever, and cognitive impairment. An in-depth investigation revealed his HIV-negative and non-diabetic status, as well as his preserved immune competence. A plain CT head showed a communicating hydrocephalus and a lumbar puncture was positive for Cryptococcus neoformans. Treatment commenced with an induction regimen encompassing amphotericin and fluconazole, concurrently maintaining the anti-tubercular treatment course. The patient's condition displayed improvement, leading to a transition to a maintenance dosage of fluconazole. This case highlighted an extraordinary occurrence of Cryptococcal meningitis in an HIV-negative patient with no history of immunosuppressant use. Notably, Cryptococcal infection should be regarded as a primary consideration in patients afflicted by pulmonary tuberculosis who subsequently present with altered consciousness. The timely identification and proper management of such instances can substantially mitigate the risks of mortality and morbidity associated with this condition.
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Affiliation(s)
| | | | - Waqar Ali
- Internal Medicine, Central Park Medical College and Teaching Hospital, Lahore, PAK
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Cryptococcal Meningitis in an HIV-Negative Puerperal Woman. Case Rep Infect Dis 2021; 2021:6665624. [PMID: 34123444 PMCID: PMC8172311 DOI: 10.1155/2021/6665624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Cryptococcal meningitis is a common opportunistic infection in HIV-infected patients and other immunocompromised people. Pregnancy, which is a state of relative immunosuppression, can also be a risk factor for the development of cryptococcal meningitis. We report a clinical case of a 41-year-old woman who developed a severe meningeal syndrome after an otherwise normal pregnancy. Cerebrospinal fluid (CSF) cytochemical analysis presented hypoglycorrhachia, high protein levels, and pleocytosis. Cryptococcal antigen tested positive in serum and CSF, and Cryptococcus neoformans was identified in the CSF culture. The diagnosis of cryptococcal meningitis was confirmed, and antifungal induction therapy was started with liposomal amphotericin B and flucytosine. After clinical improvement, induction therapy was discontinued, and the patient was discharged under maintenance therapy with fluconazole. While under antifungal maintenance therapy, the patient presented worsening of symptoms and a new brain magnetic resonance showed the development of multiple cryptococcoma. Despite sterile CSF cultures, there was a deterioration of the cytochemical parameters. The diagnosis of immune reconstitution inflammatory syndrome was assumed, and after initiation of corticotherapy, the patient improved considerably. This is a rare case of cryptococcal meningitis in a puerperal woman with a challenging management.
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Barghouthi T, Lemley R, Figurelle M, Bushnell C. Epidemiology of neurologic disease in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:119-141. [PMID: 32736746 DOI: 10.1016/b978-0-444-64239-4.00006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Many neurologic diseases in women are influenced by the physiologic and hormonal changes of pregnancy, and pregnancy itself poses challenges in both treatment and evaluation of these conditions. Some diseases, such as epilepsy and multiple sclerosis, have a high enough prevalence in the young female population to support robust epidemiologic data while many other neurologic diseases, such as specific myopathies and muscular dystrophies, have a low prevalence, with data limited to case reports and small case series. This chapter features epidemiologic information regarding a breadth of neurologic conditions, including stroke, epilepsy, demyelinating disease, peripheral neuropathies, migraine, sleep-disordered breathing, and meningioma, in women in the preconception, pregnancy, and postpartum stages.
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Affiliation(s)
- Tamara Barghouthi
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Regan Lemley
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Morgan Figurelle
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States.
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Pinz C, Mendes LT, Viana RCTP, Viana LEDO, Pinto LGT, Ogata DC. Puerpera with back pain and intermittent fever. Breathe (Sheff) 2018; 14:e48-e54. [PMID: 30131835 PMCID: PMC6095232 DOI: 10.1183/20734735.014918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 25-year-old female presented, reporting back pain and intermittent fever for 3 months. At the time, she was at the end of the third trimester of pregnancy; therefore, an imaging examination could not be carried out. Can you diagnose this case of puerpera with back pain and intermittent fever?
http://ow.ly/AC0U30k2OkF
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Cottreau JM, Barr VO. A Review of Antiviral and Antifungal Use and Safety during Pregnancy. Pharmacotherapy 2017; 36:668-78. [PMID: 27139037 DOI: 10.1002/phar.1764] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Antiviral and antifungal use in pregnancy presents challenges because of the paucity of clinical and safety data for many agents in these classes. If untreated, viral and fungal infections can have deleterious effects on both maternal and fetal health. Understanding the use and risks of these medications in pregnancy is vital to provide appropriate care. This article reviews the current literature for the use of antiviral and antifungals, the pharmacokinetics of these agents, and their safety in pregnancy.
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Affiliation(s)
- Jessica M Cottreau
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois.,Department of Pharmacy Practice, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Viktorija O Barr
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois.,Department of Pharmacy Practice, College of Pharmacy, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
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Tetart M, Trosini-Désert V, Fekkar A, Chenivesse C. [A well-inked pneumonia… can you decrypt it?]. Rev Mal Respir 2016; 34:66-69. [PMID: 27623322 DOI: 10.1016/j.rmr.2016.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We report a case of pneumonia associated with necrotic mediastinal lymph nodes in an immunocompetent patient. The case report illustrates the difficulties in making a diagnosis in necrotic mediastinal lymph nodes and discusses strategies to optimize sampling. OBSERVATION A 21-year-old immunocompetent woman was admitted to hospital with dyspnea and fever occurring ten days after delivery. Physical examination, biological results and chest X-ray led to the diagnosis of right upper lobe pneumonia. Treatment with three broad-spectrum antibiotics was ineffective. Thoracic CT-scan showed compressive mediastinal and hilar necrotic adenopathies and consolidation of the right upper lobe. Bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration was non-diagnostic. A second bronchoscopy with bronchoalveolar lavage and transbronchial needle aspiration performed in close collaboration with the mycology laboratory led to the diagnosis of cryptococcosis. Antifungal therapy with fluconazole resulted in a complete resolution of clinical and radiological signs. CONCLUSION Although it is extremely rare, pulmonary cryptococcosis should be considered in immunocompetent patients presenting with necrotic pneumonia. Effectiveness of lymph node sampling can be improved by collaboration between clinicians and microbiologists.
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Affiliation(s)
- M Tetart
- Service de pneumologie et immunoallergologie, centre de compétence des maladies pulmonaires rares, université de Lille, CHU de Lille, 59000 Lille, France
| | - V Trosini-Désert
- Service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France
| | - A Fekkar
- Service de mycologie et parasitologie, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France
| | - C Chenivesse
- Service de pneumologie et immunoallergologie, centre de compétence des maladies pulmonaires rares, université de Lille, CHU de Lille, 59000 Lille, France; Service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière-Charles-Foix, AP-HP, 75013 Paris, France.
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Zheng H, Li M, Wang D, ling Yang J, Chen Q, Zhang X, Man Y, Lao J, Chen N, Pan S. Gender-specific contributing risk factors and outcome of female cryptococcal meningoencephalitis patients. BMC Infect Dis 2016; 16:22. [PMID: 26801903 PMCID: PMC4724144 DOI: 10.1186/s12879-016-1363-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/18/2016] [Indexed: 11/12/2022] Open
Abstract
Background Although male predominance was documented in previous studies on cryptococcal meningoencephalitis (CM), there has been no statistical study about female CM patients despite recently noticeable increase in female prevalence. In the current study, we aimed to investigate the independent gender-specific contributing risk factors for onset of CM and factors related to survival time in female patients by chosen statistical tools. Methods There have been 108 patients diagnosed with CM from July 1, 1998 to June 30, 2013 in Nanfang Hospital that were included in our study. This 15-year retrospective study compared demographic and clinical features of 31 female patients with 77 males. Multivariate analysis was performed for detection of the contributors to the onset of CM in female patients. The independent variables for multivariate analysis were selected according to statistical significance in univariate analysis. Furthermore, Cox regression model was used to evaluate the factors related to survival length. Results Use of corticosteroids or other immunosuppressants (32.3 % versus 11.7 %; p = 0.011) and history of systemic lupus erythematosus (SLE) and other autoimmune diseases (29 % versus 3.9 %; p < 0.001) were more common in females, but only the history of SLE or other autoimmune diseases was significant (OR 10.59, 95 % CI 1.49-74.77, p = 0.02) by multivariate analysis. The ratio of cerebrospinal fluid (CSF) glucose-to-blood glucose was related to the survival time (p = 0.03, 95 % CI 0-0.71). Conclusions The results showed that the history of SLE or other autoimmune diseases rather than chronic use of corticosteroids and/or immunosuppressants was the independent gender-specific contributing risk factor in female CM patients. Therefore, more attention should be made to the prevention of infection from the genus Cryptococcus spp. in female patients with SLE or other autoimmune diseases. In addition, decreased ratio of CSF glucose-to-blood glucose before antifungal therapy predicted the worse prognosis.
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Affiliation(s)
- Hui Zheng
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Mingyue Li
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Jia ling Yang
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Qiong Chen
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Xiaomei Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Yang Man
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Junying Lao
- Medical Records Room, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Ningfen Chen
- Medical Records Room, Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, People's Republic of China.
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, No.1838 North Guangzhou Avenue, Guangzhou City, Guangdong Province, People's Republic of China.
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Cryptococcus neoformans var. grubii Infection in HIV-Seronegative Patients from Northeast India: Report of Two Cases with Review of Literature. Mycopathologia 2015; 181:315-21. [DOI: 10.1007/s11046-015-9971-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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Mittal N, Vatsa S, Minz AKA. Fatal meningitis by Cryptococcus laurentii in a post-partum woman: A manifestation of immune reconstitution inflammatory syndrome. Indian J Med Microbiol 2015; 33:590-3. [DOI: 10.4103/0255-0857.167337] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Pilmis B, Jullien V, Sobel J, Lecuit M, Lortholary O, Charlier C. Antifungal drugs during pregnancy: an updated review. J Antimicrob Chemother 2014; 70:14-22. [PMID: 25204341 DOI: 10.1093/jac/dku355] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Antifungal prescription remains a challenge in pregnant women because of uncertainties regarding fetal toxicity and altered maternal pharmacokinetic parameters that may affect efficacy or increase maternal and fetal toxicity. We present updated data reviewing the available knowledge and current recommendations regarding antifungal prescription in pregnancy. Amphotericin B remains the first-choice parenteral drug in spite of its well-established toxicity. Topical drugs are used throughout pregnancy because of limited absorption. Recent data have clarified the teratogenic effect of high-dose fluconazole during the first trimester and provided reassuring cumulative data regarding its use at a single low dose in this key period. Recent data have also provided additional safety data on itraconazole and lipidic derivatives of amphotericin B. Regarding newer antifungal drugs, including posaconazole and echinocandins, clinical data are critically needed before considering prescription in pregnancy.
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Affiliation(s)
- Benoît Pilmis
- Infectious Diseases Department, Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris, France
| | - Vincent Jullien
- Pharmacology Department, Université Paris Descartes, Sorbonne Paris Cité, Inserm U1129, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jack Sobel
- Wayne State University, Detroit, MI, USA
| | - Marc Lecuit
- Infectious Diseases Department, Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris, France
| | - Olivier Lortholary
- Infectious Diseases Department, Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris, France
| | - Caroline Charlier
- Infectious Diseases Department, Université Paris Descartes, Sorbonne Paris Cité, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, Paris, France
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Hagan JE, Dias JS, Villasboas-Bisneto JC, Falcão MB, Ko AI, Ribeiro GS. Puerperal brain cryptococcoma in an HIV-negative woman successfully treated with fluconazole: a case report. Rev Soc Bras Med Trop 2014; 47:254-6. [PMID: 24861306 DOI: 10.1590/0037-8682-0215-2013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/22/2014] [Indexed: 11/22/2022] Open
Abstract
Cryptococcus spp. cerebral abscesses are uncommon in immunocompetent subjects. The recommended induction treatment is the administration of amphotericin B plus flucytosine combined with resection for lesions ≥3cm. In this paper, we describe an HIV-negative woman diagnosed with a large cryptococcoma in the immediate postpartum period. The lesion was not resected, and due to amphotericin B intolerance, she received an extended course of fluconazole monotherapy. There was no disease recurrence during the 4 years of follow-up. The abrupt onset of her symptoms following delivery suggests that she developed a postpartum immune reconstitution syndrome. This case also demonstrates that in specific situations fluconazole monotherapy can be attempted in immunocompetent patients with cryptococcoma.
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Affiliation(s)
- José Edward Hagan
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Jesângeli Sousa Dias
- Hospital Couto Maia, Secretaria de Saúde do Estado da Bahia, Salvador, BA, Brasil
| | | | | | - Albert Icksang Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Guilherme Sousa Ribeiro
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, BA, Brasil
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Kruetzelmann A, Sobottka I, Fiehler J, Tolosa E, Gerloff C, Rosenkranz M. Relapsing cerebral aspergilloma associated with pregnancy. Clin Neurol Neurosurg 2013; 115:1154-6. [DOI: 10.1016/j.clineuro.2012.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 08/17/2012] [Accepted: 09/15/2012] [Indexed: 11/26/2022]
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Lymphocyte transformation assay for C neoformans antigen is not reliable for detecting cellular impairment in patients with neurocryptococcosis. BMC Infect Dis 2012; 12:278. [PMID: 23110700 PMCID: PMC3556098 DOI: 10.1186/1471-2334-12-278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 10/17/2012] [Indexed: 11/10/2022] Open
Abstract
Background Cryptococcus neoformans causes meningitis and disseminated infection in healthy individuals, but more commonly in hosts with defective immune responses. Cell-mediated immunity is an important component of the immune response to a great variety of infections, including yeast infections. We aimed to evaluate a specific lymphocyte transformation assay to Cryptococcus neoformans in order to identify immunodeficiency associated to neurocryptococcosis (NCC) as primary cause of the mycosis. Methods Healthy volunteers, poultry growers, and HIV-seronegative patients with neurocryptococcosis were tested for cellular immune response. Cryptococcal meningitis was diagnosed by India ink staining of cerebrospinal fluid and cryptococcal antigen test (Immunomycol-Inc, SP, Brazil). Isolated peripheral blood mononuclear cells were stimulated with C. neoformans antigen, C. albicans antigen, and pokeweed mitogen. The amount of 3H-thymidine incorporated was assessed, and the results were expressed as stimulation index (SI) and log SI, sensitivity, specificity, and cut-off value (receiver operating characteristics curve). We applied unpaired Student t tests to compare data and considered significant differences for p<0.05. Results The lymphotoxin alpha showed a low capacity with all the stimuli for classifying patients as responders and non-responders. Lymphotoxin alpha stimulated by heated-killed antigen from patients with neurocryptococcosis was not affected by TCD4+ cell count, and the intensity of response did not correlate with the clinical evolution of neurocryptococcosis. Conclusion Response to lymphocyte transformation assay should be analyzed based on a normal range and using more than one stimulator. The use of a cut-off value to classify patients with neurocryptococcosis is inadequate. Statistical analysis should be based on the log transformation of SI. A more purified antigen for evaluating specific response to C. neoformans is needed.
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Lachhab L, Rasmouni K, Ait Ben Haddou EH, Maamar M, Seffar M, Regragui W, Benomar A, Yahyaoui M. Cryptococcosis in an immunocompetent pregnant woman. Rev Neurol (Paris) 2012; 169:92-3. [PMID: 22766327 DOI: 10.1016/j.neurol.2012.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 03/25/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nayak SU, Talwani R, Gilliam B, Taylor G, Ghosh M. Cryptococcal Meningitis in an HIV-Positive Pregnant Woman. ACTA ACUST UNITED AC 2011; 10:79-82. [PMID: 21317164 DOI: 10.1177/1545109710387434] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cryptococcal meningitis is uncommon in pregnant HIV-infected women. The clinical care of an HIV-1 positive pregnant woman with cryptococcal meningitis whose pathology has been previously reported is reviewed to highlight the treatment of the disease and some of the challenges associated with antifungal therapy during pregnancy, including the teratogenicity of antifungal agents, their variable pharmacokinetics in pregnancy, the lack of well-defined treatment duration for such infections, and host factors including compliance. This patient's disease relapsed due to nonadherence after an initial course of intravenous amphotericin. Subsequently, she was successfully treated, with a favorable fetal outcome, with another 2 weeks of amphotericin B, followed by consolidation and maintenance with fluconazole and antiretroviral treatment. This case highlights and reviews the complexities of the management of cryptococcal meningitis in HIV-infected pregnant women.
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Affiliation(s)
- Seema U Nayak
- Department of Medicine, Division of Infectious Diseases, George Washington University Medical Center, Washington, DC, USA,
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Njoku JC, Gumeel D, Hermsen ED. Antifungal Therapy in Pregnancy and Breastfeeding. CURRENT FUNGAL INFECTION REPORTS 2010. [DOI: 10.1007/s12281-010-0009-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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